The patient's behaviour is a pivotal factor in the success of any healthcare intervention but it seems that an understanding of how patients really behave is often missing from healthcare strategy, planning and intervention design. This blog will discuss some of what we already know can make a difference, some of what I think will help, and some of the obstacles to change that we need to deal with.
I focus on the analysis and design of healthcare systems and intervention programmes aimed at changing patient behaviour for better health outcomes. I have more than three decades of experience in applied health psychology research and practice with clients in the public sector and the health technology, pharma and insurance industries.

07/10/2013

Dealing With Resistance To Change

Technological
advances in healthcare raise the question of the behaviour changes required of
people for the successful implementation of the technology. The biggest
obstacles to healthcare system evolution may not be technological, but human –
the thoughts, feelings and relationships of the people working in and on
healthcare. Without behaviour change strategies to address these human factors,
innovations in technology and processes may have limited impact.

Thesis
number one. Those who aspire to be innovators should expect their genius to
create bother for people. Sure, the world will come to thank us one day but
until then, the world will act like ungrateful Luddites. Chances are, our
innovation will require people to change their behaviour and as a general rule,
people don’t like to change their behaviour, even if it is problematic to them.
“The devil you know . . .” etc.

Thesis
number two. Innovations have no real value independent of the people who use
them. This is a matter not just of whether
value will be realized but also of what
that value actually looks like. The inventor of the screwdriver intended
for it to be used to twist screws, not lever objects apart. The screwdriver is
not designed to be a jemmy bar and it is not particularly good at it. But if I
need a jemmy bar, have no jemmy bar but do have a screwdriver and it might do the job, I will re-purpose it without further thought. The realised value of
the screwdriver, qua jemmy bar, was clearly determined by me, not the
innovator[1].

Thesis
number three. No-one comes to an innovation as a blank slate, no matter how
never-before-seen it might be. Established conceptual schemas and habits will
be automatically applied to the novel situation – even to the extent that a
person might not recognize the innovation as being something of relevance to
them. If we attempt to tell them what it is, why it is a good idea and how to
use it, their response will still be mediated by their prior learning. Do they
see us as trustworthy? Are they ready to adapt to something new? Do they have
the capability to utilize the innovation? And so on.

To give a
bright idea the best chance of delivering on its potential, we must think of
the end-users as collaborators in our project. We need an implementation plan
that focuses clearly on their pivotal role in the final success of the idea. We
must be aware of the behaviour change burden that we are asking of them.

Michie et
al (2011)[2]
have proposed an interesting conceptual framework for behaviour change that I
think could be useful here. Although their work has the health-related
behaviour of patients in mind, I think its conceptual framework is useful to
our strategic thinking and its behaviour change principles are very relevant to
behaviour changes required by innovations of clinicians, administrators and
others involved in healthcare.

The model,
called the Behaviour Change Wheel (Figure 1), arranges the factors that moderate
behaviour change into three zones: policy instruments, intervention processes
and individual characteristics.

At the heart of the system lie the individual’s motivation, ability and opportunity to change their behaviour. Each of these factors can be influenced by a range of intervention processes, targeting whichever individual characteristics are presenting obstacles to change.

These
intervention processes are subject to an environment shaped by policy
instruments which empower, support and signal the behavioural outcomes required.

Successful
behaviour change strategy involves accurate identification of the individual
characteristics to be targeted and alignment of the congruent intervention
processes and policy settings. This is not usually simple and straight-forward
but it is eminently achievable. We already have plenty of knowledge, tools and
capability in every component of this model and investment in research that
treated end-users as active participants in product development would surely
yield more.

It seems to
me that the three sectors of the Wheel demarcate three groups of people with
differing powers and responsibilities; politicians, planners and policy-writers
work in the Policy zone, healthcare scientists and professionals devise and
apply the interventions, and the end-users (whether patients, healthcare workers,
or others) of course are ultimately responsible for their own behaviour.

The three
sectors are intertwined and constitute a ‘system’, so the implications of an
innovation should be considered in all three sectors – what behaviour-change
demands does it make of the patient, the clinician and the administrator? Does each of these collaborators in our innovation
have the capability, motivation and opportunity to make the required changes? What
interventions can we apply to assist them with the changes and how does the
policy environment affect our ability to apply these interventions and the behaviour-changes
themselves?

[1] For
a detailed discussion of how technological value is a co-creation of the
innovators and the end-users in healthcare, see Mol, A. (2008). The Logic of
Care: Health and the Problem of Patient Choice, Oxford, Routledge Press.

Comments

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Hi Grant, form a HIT perspective I think this model doesn't give a ready role for technology incumbency which I envision as a shadow across the diagram. Can you suggest how it explains incumbency and/or how it can explain how to dislodge technological incumbency, especially given a lot of money has been spent on it and there is little administrative interest in change despite the need and value at the clinical level.

Thanks for your comment, Jon. I think I agree - and this is an important consideration that I did not address in this article.

Incumbency can generate 'policy'-type factors (information security and capital investment policies are a couple that spring to mind), 'intervention' factors (things that the incumbent technology can and can't do, for example) and behavioural factors (over-learned processes shaped by the incumbent technology, perhaps).

I still see utility in the Behaviour Change Wheel for unpacking the challenge presented by incumbency but it is very useful to explicitly consider incumbency as a source of resistance to change.

With a professional background as a clinical psychologist and health psychologist, I have more than 30 years of experience in healthcare service delivery, intervention design, organisational development and leadership - most recently Director of the intervention design and R&D teams at a leading, multinational provider of medication adherence and patient support programmes. I believe strongly in the importance of patient behaviour as a determinant of healthcare outcomes.

How can we design health service systems and interventions that better match what patients are really like and thereby deliver better healthcare outcomes and better returns on investment?

This blog discusses some of what we already know can make a difference, some of what I think will help, and some of the obstacles to change that we need to deal with. Please join the discussion: add your comments, subscribe to the feed or email me directly.